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COVID-19 Pandemic in Indonesia: Situation and Challenges of Rehabilitation

Medicine in Indonesia

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 SPECIAL ARTICLE

COVID-19 Pandemic in Indonesia: Situation and Challenges

of Rehabilitation Medicine in Indonesia

Boya Nugraha1, Luh K. Wahyuni2, Hening Laswati3, Peni Kusumastuti4,

Angela B.M. Tulaar2, Christoph Gutenbrunner1
1
Department of Rehabilitation Medicine, Hannover Medical School, Hannover, Germany.
2
Department of Physical Medicine and Rehabilitation, Faculty of Medicine Universitas Indonesia - Cipto
Mangukusumo Hospital, Jakarta, Indonesia.
3
Department of Physical Medicine and Rehabilitation, Faculty of Medicine Universitas Airlangga - Dr. Soetomo
General Academic Hospital, Surabaya, Indonesia.
4
Medical Rehabilitation Department, Fatmawati Hospital, Jakarta, Indonesia.

Corresponding Author:
Boya Nugraha, MD. Department of Rehabilitation Medicine, Hannover Medical School, Hannover, Germany.
email: boya.nugraha@gmail.com.

ABSTRAK
COVID-19 telah menjadi pandemik di Indonesia sejak ditemukannya kasus pertama pada tanggal 2 Maret
2020 di Depok. Peningkatan kasus perhari semakin tinggi sejak akhir Agustus 2020 yang mencapai lebih dari
2000 kasus per hari. Sistem kesehatan di Indonesia perlu ditingkatkan dalam hal kapasitas, termasuk rehabilitasi
medik yang harus dilibatkan dari fase akut hingga jangka panjang dalam penanganan pasien COVID-19.
Rehabilitasi medik juga diperlukan untuk pasien lain yang bukan COVID-19. Pentingnya keterlibatan, pelayanan
rehabilitasi medik dan implementasinya dimasa pandemic COVID-19 memerlukan strategi tersendiri yang harus
dilakukan baik oleh pekerja kesehatannya, rumah sakit dan kebijakan pemerintah. Hal ini diperlukan untuk
percepatan peningkatan kesehatan pasien, percepatan pemulangan dan menghindari readmisi pasien, dan juga
pengoptimalan program kembali bekerja untuk pasien yang sembuh dari COVID-19.

Kata kunci: COVID-19, rehabilitation, health care, rehabilitation services, pandemic.

ABSTRACT
COVID-19 has become a pandemic in Indonesia since the first cases have been positively diagnosed on 2
March 2020 in Depok. The cases have been increased gradually since the end of August 2020 that has reached
1000 cases per day. The health system in Indonesia needs to be improved in terms of capacity, including
rehabilitation medicine that should be involved in all health phases (from acute to long-term) in managing
patients with COVID-19. Rehabilitation is also still needed for other non-COVID-19 patients. The importance
of involvement and implementation of rehabilitation services during the COVID-19 pandemic will need special
strategies that should be done by rehabilitation professionals, hospitals, and government. These are necessary
to accelerate the improvement of patients’ health, discharge, and avoid re-admission, as well as optimize return-
to-work for patients who are recovered from COVID-19.

Keywords: COVID-19, rehabilitation, health care, rehabilitation services, pandemic.

Acta Med Indones - Indones J Intern Med • Vol 52 • Number 3 • July 2020 299
Boya Nugraha Acta Med Indones-Indones J Intern Med

INTRODUCTION The confirmed cases of COVID-19 in

The COVID-19 pandemic that has started
in Wuhan, China, has been spread all over the
world since the end of 2019.1 Covid-19 can
infect all individuals of all ages,2-4 and people at
all levels of economic status.3 However, persons
with a high risk of severe or fatal course of the
disease are older individuals and people with
comorbidity, such asdiabetes, cancer, and other
chronic diseases.5-7
In Indonesia, the first cases of COVID-19
patients were identified on 2 March 2020 in
Depok. Since the ends of August 2020, the
number of new positively tested cases in
Indonesia have reached more than two thousand
per day (Figure 1). Currently (as of 8 September
2020), the total number of positively diagnosed
cases reached more than 196,000.8
Indonesia are placed the second among
Association of South-East Asia Nations (ASEAN)
countries (Table 1). However, the numbers of
deaths are the highest. Both numbers of positive
and death cases will keep increasing, considering
the current total tested per Million populations
in Indonesia are still low as compared to other
countries. It seems that Indonesia will still need
time to flatten the curve. Although the recovered
cases are the highest among ASEAN countries,
it does not mean that all recovered patients are
without any lingering effects, such as fatigue,
dyspnea, joint pain, chest pain, headache, muscle
weakness, neurological symptoms, and mental
health problems. 9 Therefore, the recovered
patients still need treatments, which mostly
related to rehabilitation.

Figure 1. Data of COVID-19 in Indonesia.8

Table 1. Covid-19 cases in ASEAN countries (as of 7 September 2020).10

Test/1M
Countries Confirmed cases Total deaths Total recovered Total population
Population
Philipines 238,727 3,890 184,906 25,855 109,850,251
Indonesia 196,989 8,130 140,652 8,948 274,061,093
Singapore 57,044 27 56,408 353,013 5,858,949
Malaysia 9,459 128 9,124 40,300 32,422,628
Thailand 3,445 58 3,281 10,729 69,833,165
Vietnam 1,049 35 853 10,350 97,501,966
Myanmar 1,518 8 388 3,055 54,478,228
Cambodia 274 -- 272 6,356 16,761,610
Brunei 145 3 139 121,013 438,259
Laos 22 -- 21 5,714 7,294,985

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Vol 52 • Number 3 • July 2020 COVID-19 pandemic in Indonesia: Situation and challenges of rehabilitation
Similar to other countries all over the world,
the government of Indonesia has been awaiting the
development of effective medicine and vaccines.
From the perspective of public health issues, many
issues need to be taken promptly and accurately.
During this period, some important actions have
been also implemented by the government of
Indonesia in order to reduce, control and mitigate
the spread of SARS-CoV-2 infection, particularly
by following actions: (1) Physical distancing,
hand washing, cough and sneeze etiquette, as
well as isolation; (2) Massive detection/testing for
COVID-19 (both by swab test and/or rapid test)
and tracing; (3) Increasing capacity of hospitals,
particularly hospitals that are appointed as referral
hospitals for COVID-19 patients; (4) Establishing
national COVID-19 emergency team.
According to the survey that was held
by the World Health Organization (WHO),
the COVID-19 pandemic has influenced the
health services worldwide, particularly in the
low-and middle-income countries.10 In spite of
rehabilitation play a major role in recovery after a
severe illness due to COVID-19, the most effected
health service is rehabilitation.11 It was effected
rehabilitation services in 63% out of 153 countries
that were surveyed, particularly in low-and low-
middle income countries.11 Therefore, WHO
has urged their member states that rehabilitation
Figure 2. Phase-specific rehabilitation response for patients with SRAS-CoV-2 infection.
should be integrated into the national strategy for
managing the COVID-19 pandemic.11
Considering the importance and relevancies
of rehabilitation medicine during COVID-19,
several important and relevant points need to
be highlighted and discussed for Indonesia.
These include: (a) What are the rehabilitation
needs for COVID-19 patients; (b) The effects of
reducing the capacity of rehabilitation services
for other patients (non-COVID-19) in need for
rehabilitation (e.g. people with disability, patient
with chronic diseases (e.g. cancer, traumatic
brain injury, spinal cord injury, stroke, diabetes,
chronic pain, etc); (c) Situation and challenges of
rehabilitation medicine in long-term COVID-19
pandemic in Indonesia.
REHABILITATION NEEDS FOR COVID-19
PATIENTS
It has been known that the primary problem
of patients with COVID-19 is respiratory
functions. This was particularly due to the
cytokine storm12,13 that leads to acute respiratory
distress syndrome. The symptoms in moderate
and severe problem patients, particularly related
to the respiratory impairments (e.g. difficult
to breathe). However, many findings have
reported also non-pulmonary manifestations
and complications problems.14 These include
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Boya Nugraha Acta Med Indones-Indones J Intern Med

muscle weakness, delirium, swallow and
communication problems, neurological and
psychiatric sequelae.15 Therefore, patients with
moderate and severe cases of COVID-19 have
a high need for rehabilitation interventions.16
Additionally, rehabilitation for COVID-19
patients should be implemented in all phases
(acute to long-term phases).16 This also can be
seen in Figure 2.
COVID-19 is still not yet fully understood,
however, many studies related to the mechanisms
of this disease (many of them are observational)
have been published. It becomes more and
more evident, that the disease is not only
an airway infection but also causes a hyper-
immune response in the body.12,17-19 This may
explain the broad spectrum of long-term organ
dysfunction and functional symptoms. 20,21
Many of the symptoms and dysfunctions can
be treated by rehabilitation interventions. As
clinical outcome studies have not yet been
performed, the approach at this stage is pragmatic
and symptom-oriented. The main symptoms
observed frequently are summarized in Table
2, and pragmatic rehabilitation approaches
are listed (for more details see literature and

Table 2. Overview of clinical/organ impairment due to SARS-CoV-2 infections, rehabilitation needs, and interventions.

Rehabilitation interventions
Organ system Hospitalized patients Discharged patients
Symptoms with
and functioning
rehabilitation needs Acute care
problems Early-post acute Post-acute Long-term
(including critical
care rehabilitation rehabilitation
care)
Respiratory Respiratory Breathing exercise, Breathing exercise, Breathing exercise, aerobic
system insufficiency, low positioning assistive respiration exercise, nutritional support
oxygen uptake treatment, early
mobilization
Central and Headache, dizziness, Passive and Assisted and Coordinative training, gait
peripheral confusion, pain, assisted active movements, training, training of activities of
nervous system consciousness, movements, neurophysiological daily living, cognitive training
delirium, cognitive sensory stimulation, techniques, (incl. telerehabilitation)
dysfunction early mobilization sensory stimulation,
Stroke cognitive training

Sensory dysfunction, Smell training Smell training

i.e. smell and taste
dysfunction
Dysphagia, Dysphagia management, speech therapy Dysphagia management,
communication speech therapy (incl.
problems telerehabilitation)
Paresthesia, Coordination exercise, sensory stimuli Coordination exercise, sensory
dyscoordination stimuli
Musculoskeletal Muscle weakness an Passive an assisted Assisted and active Aerobic training, muscle
system muscular imbalance, movements, mobilization and strengthening exercise,
muscle pan muscle balancing, positioning, adapted balancing muscle tone
early mobilization muscle exercise
Cardiovascular Myopericarditis, Graded early mobilization, peripheral Graded aerobic exercise
system hypoxia, heart failure vascular training
Thrombosis Passive movements, respiratory training, Active dynamic muscular
compression, positioning exercise, compression
treatment
Pain Generalized pain Physical modalities Graded activities Aerobic exercise, muscle
(fibromyalgia-like balancing, cognitive behavioral
symptoms) treatment
Mental health Depression, anxiety Coping strategy Coping strategy, Exercise, Social
exercise psychotherapy reintegration
Autonomous Fatigue, reduced Passive physical Passive physical Aerobic training, sleep
regulation general physical stimuli stimuli, graded hygiene, coping strategies
performance, sleep exercises
disorders

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Vol 52 • Number 3 • July 2020 COVID-19 pandemic in Indonesia: Situation and challenges of rehabilitation
surveys on Cochrane Rehabilitation.22 Of course
selection of treatments and intensity must be
individually adapted by skilled rehabilitation
physicians, and team integrated rehabilitation
will be essential. All of the rehabilitation
interventions should be supported with well-
defined functional assessment by physical and
rehabilitation medicine (PRM) physicians. The
functional assessment, particularly at acute and
early acute phases, should consider comorbid
aspects that could lead to pneumonia and
mortality; functional impairment (existed and
impending) which is caused by SARS-CoV-2
infection; actual functional capacities that could
support the recovery process and improvement of
quality of life.23 It is also important to stress that
the long term dysfunction has a high impact on
the quality of life and participation (i.e. unfitness
for work). This also is a strong argument of why
rehabilitation must be provided for patients after
COVID-19.24
From the perspective of care planning
it is recommended to set-up specialized
rehabilitation centers (within existing
rehabilitation units), and to build up networks
of partners in the community. Teleconsulting
and telerehabilitation will be core elements to
adequately manage the complex problems as
well as the growing number of persons with a
need for acute rehabilitation and suffering from
long-term symptoms.25
Taken together, rehabilitation plays a major
role in managing the health-related issue of
COVID-19 patients for both hospitalized and
discharged patients. However, rehabilitation
interventions in this situation are quite complex
and need well-trained professionals. This is due
to the complex of hygiene regulations, specific
training, and personal protective equipment
that are needed to handle this specific group of
patients.
In addition to the above-mentioned
problems, participation is also a problem
for post-COVID-19 patients, which include
unfitness to work and other social integration
issues. These also should be managed by
vocational rehabilitation, stepwise re-
integration, social activities, and family-
oriented psychotherapy.
THE EFFECTS OF REDUCING THE CAPACITY
OF REHABILITATION SERVICES FOR OTHER
PATIENTS (NON-COVID-19) IN NEED FOR
REHABILITATION (E.G PEOPLE WITH
DISABILITY, PATIENT WITH CHRONIC
DISEASES (E.G. CANCER, TRAUMATIC
BRAIN INJURY, SPINAL CORD INJURY,
STROKE, DIABETES, CHRONIC PAIN, ETC)
As aforementioned, rehabilitation services
have been disrupted during COVID-19, including
in Indonesia. Not only in top referral hospitals
but also in rehabilitation practices (e.g. PRM
practices, physiotherapy practices, etc.) have
reduced the capacity during the COVID-19
pandemic. This capacity reduction is not only
because of prevention of the spreading the SARS-
COV-2 infection, but also the need of hygiene
and special personal protective equipment.
These increase the health cost, too. Because of
these issues, many non-COVID-19 patients who
are in need of rehabilitations have delayed of
treatment that could lead to complications and
consequently increase the functioning deficits.
In addition to the existing patients who
are in need of rehabilitation, such as stroke,
musculoskeletal, cancer and cancer survivor,
spinal cord injury, diabetes, and others, the
COVID-19 patients (both in and outpatients) need
to have special concerns. As aforementioned,
COVID-19 patients and their survivors need
multi-rehabilitation interventions from a multi-
professional team in rehabilitation. These should
also take into account when prioritizing and
managing patients in rehabilitation needs.
S I T U AT I O N , C H A L L E N G E S , A N D
RECOMMENDATION OF REHABILITATION
MEDICINE IN LONG-TERM COVID-19
PANDEMIC IN INDONESIA
It is predicted that COVID-19 will last
longer.26 It means, a different aspects of life will
be affected. From an economic perspective,
long-term COVID-19 can lead also to poverty.27
As it is known, poverty and disability are
bidirectional. 28 Therefore in the long-term
pandemic, it will increase also the prevalence
of disability worldwide, including in Indonesia.
Prior to the pandemic of COVID-19, health-
related issues in Indonesia still needed to be
improved, including in the field of rehabilitation
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Boya Nugraha
medicine.29 The issue was not only the lack of
health professionals but also health provisions.
These issues are also worsened due to an uneven
distribution of both rehabilitation professionals
and rehabilitation provision all over Indonesia,29
which are being taken into consideration and
improved by The National Organization of the
Indonesian Physical Medicine and Rehabilitation
Specialists through several strategic plans.
As rehabilitation can shorten the length of
stay in all phases of healthcare, optimize health
outcomes, avoid re-admission, reduce health care
and social cost, increase the employment rate for
COVID-19 survivors, and strengthen the health
care workforces, therefore, in order to achieve
the highest level and quality of rehabilitation
services during (and in the cases of long-term)
COVID-19, some recommendations need to
be considered. The following are generic list
recommendations in the field of rehabilitation
medicine based on practical and opinion of
authors at different levels of health systems.
At the Government Level
1. As suggested by WHO11, rehabilitation
should be included as an integral part of
the national strategy for the COVID-19
pandemic.
2. Improve rehabilitation capacity and
rehabilitation service-related financing for
COVID-19 patients.
3. Ensure that other persons in need for
rehabilitation get access to good quality
rehabilitation services.
At the Hospital Level
1. Make available rehabilitation services at all
phases of health care (acute to long-term)
in the COVID-19 referral hospitals (early
rehabilitation and outpatient services).
2. In the case of insufficiency, prioritize patients
based on needs and the risk of having
complications.
3. Increase the capacity of rehabilitation
services in order to treat other non-COVID-19
patients with rehabilitation needs.
4. I m p l e m e n t t e l e r e h a b i l i t a t i o n a s a
complementary treatment for patients.
5. Implement prevention and rehabilitation
programs for health workforces who are in
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Acta Med Indones-Indones J Intern Med
charge of COVID-19 patients.
6. Include hygiene and personal protection
equipment when treating COVID-19 patients.
At Health Professional Level
1. Rehabilitation professionals should
collaborate with all other health professionals
in order to achieve an effective and
optimal health outcomes in general (inter-
professional).
2. Collaboration with health rehabilitation
professionals to deliver quality rehabilitation
services (team integration/multi-professional
rehabilitation).
3. In order to fill in the gap of health
professionals in rehabilitation, training
basic rehabilitation programs related to the
symptoms of COVID-19 patients for other
health professionals, like nurses, general
practitioners, and others such as CBR
workers, family, and others are needed for
treating recovered patients.
CONCLUSION
Hopefully, the presented situation of
COVID-19 pandemic and rehabilitation medicine
in Indonesia, as well as list of recommendations,
can be considered in managing the COVID-19
pandemic by relevant stakeholders.
REFERENCES
1. Sohrabi C, Alsafi Z, O’Neill N, et al. World Health
Organization declares global emergency: A review of
the 2019 novel coronavirus (COVID-19). Int J Surg.
2020;76:71-6.
2. Ovali F. SARS-CoV-2 infection and the newborn. Front
Pediatr. 2020;8:294.
3. Lloyd-Sherlock P, Ebrahim S, Geffen L, McKee M.
Bearing the brunt of covid-19: older people in low and
middle income countries. BMJ. 2020;368:m1052.
4. Lithander FE, Neumann S, Tenison E, et al. COVID-19
in older people: a rapid clinical review. Age Ageing.
2020; 49:501-15.
5. Fuellen G, Liesenfeld O, Kowald A, et al. The
preventive strategy for pandemics in the elderly is to
collect in advance samples & data to counteract chronic
inflammation (inflammaging). Ageing Res Rev. 2020:
101091.
6. Katulanda P, Dissanayake HA, Ranathunga I, et al.
Prevention and management of COVID-19 among
patients with diabetes: an appraisal of the literature.
Diabetologia. 2020.
 Vol 52 • Number 3 • July 2020 COVID-19 pandemic in Indonesia: Situation and challenges of rehabilitation
7. Martini N, Piccinni C, Pedrini A, Maggioni A.
CoViD-19 and chronic diseases: current knowledge,
future steps and the MaCroScopio project. Recent Prog
Med. 2020;111:198-201.
8. COVID-19 STP. Peta sebaran COVID-19. cited on 21
August 2020. Available from: https://covid19.go.id/
peta-sebaran.
9. Carfi A, Bernabei R, Landi F, Gemelli Against C-P-
ACSG. Persistent symptoms in patients after acute
COVID-19. JAMA. 2020.
10. worldometers.info. COVID-19 Coronavirus pandemic.
cited on: 8 September 2020. Available from: https://
www.worldometers.info/coronavirus/.
11. WHO. COVID-19 significantly impacts health
services for noncommunicable diseases. cited on: 20
August 2020. Available from: https://www.who.int/
news-room/detail/01-06-2020-covid-19-significantly-
impacts-health-services-for-noncommunicable-
diseases.
12. Channappanavar R, Perlman S. Evaluation of
activation and inflammatory activity of myeloid cells
during pathogenic human Coronavirus infection.
Methods Mol Biol. 2020;2099:195-204.
13. Lau SKP, Lau CCY, Chan KH, et al. Delayed induction
of proinflammatory cytokines and suppression of
innate antiviral response by the novel Middle East
respiratory syndrome coronavirus: implications for
pathogenesis and treatment. J Gen Virol. 2013;94:
2679-90.
14. Lopez M, Bell K, Annaswamy T, Juengst S, Ifejika
N. COVID-19 Guide for the rehabilitation clinician:
A review of nonpulmonary manifestations and
complications. Am J Physic Med Rehab. 2020;99:669-
73.
15. Orsini A, Corsi M, Santangelo A, et al. Challenges
and management of neurological and psychiatric
manifestations in SARS-CoV-2 (COVID-19) patients.
Neurol Sci. 2020;41:2353-66.
16. PAHO. Rehabilitation considerations during the
COVID-19 outbreak 2020; 2020.
17. Gomez-Rial J, Rivero-Calle I, Salas A, Martinon-
Torres F. Role of monocytes/macrophages in Covid-19
pathogenesis: Implications for therapy. Infect Drug
Resist. 2020;13:2485-93.
View publication stats
18. Chowdhury MA, Hossain N, Kashem MA, Shahid MA,
Alam A. Immune response in COVID-19: A review. J
Infect Public Health. 2020.
19. Bhaskar S, Sinha A, Banach M, et al. Cytokine storm in
COVID-19-immunopathological mechanisms, clinical
considerations, and therapeutic approaches: The
REPROGRAM consortium position paper. Frontiers
Immunol. 2020;11:1648.
20. Belli S, Balbi B, Prince I, et al. Low physical
functioning and impaired performance of activities
of daily life in COVID-19 patients who survived the
hospitalisation. Eur Respir J. 2020.
21. Lopez C, Closa C, Lucas E. Telemedicine in
rehabilitation: Post-COVID need and opportunity.
Rehabilitacion (Madr). 2020.
22. Rehabilitation C. Cochrane rehabilitation. Cited on:
21 August 2020. Available from: https://rehabilitation.
cochrane.org/.
23. RSCM. Covid-19 clinical practice guideline. Jakarta:
RSCM, 2020.
24. Gutenbrunner C, Stokes EK, Dreinhofer K, et al. Why
rehabilitation must have priority during and after the
COVID-19-pandemic: A position statement of the
Global Rehabilitation Alliance. J Rehab Med. 2020;
52: jrm00081.
25. Salawu A, Green A, Crooks MG, Brixey N, Ross
DH, Sivan M. A proposal for multidisciplinary tele-
rehabilitation in the assessment and rehabilitation of
COVID-19 survivors. Int J Environ Res Public Health.
2020;17.
26. Helmholtz. Is it possible to predict an end to the corona
crisis? Cited on: 21 August 2020. Available from:
https://www.helmholtz.de/en/health/is-it-possible-to-
predict-an-end-to-the-corona-crisis/.
27. Bank TW. Projected poverty impacts of COVID-19
(coronavirus). Cited on: 21 August 2020. Available
from: https://www.worldbank.org/en/topic/poverty/
brief/projected-poverty-impacts-of-COVID-19.
28. UN. Realization of the sustainable development goals
by, for and with persons with disabilities. 2018; New
York: United Nations; 2018.
29. Nugraha B, Setyono GR, Defi IR, Gutenbrunner C.
Strengthening rehabilitation services in Indonesia: A
brief situation analysis. J Rehab Med. 2018;50:377-84.
305